Task Force on Mental Health and Wellbeing

DRAFT RECOMMENDATIONS – May 3, 2017

Mental health issues are quite common among American college students. This includes severe mental illness such as depression, anxiety, and substance use disorder as well as issues related to lack of optimal mental health and reduced resilience in the context of the highly stressful experience of undergraduate and graduate education. College and graduate education at a rigorous university is by its nature a challenging and potentially stressful experience, often coinciding with other critical life course events such as emerging adulthood, new independence, adult relationships, and family responsibilities. The university cannot entirely remove these sources of stress, but, rather, can offer a supportive academic environment that recognizes these challenges and supports students.

The Task Force on Student Mental Health and Wellbeing gathered extensive information on the experience of
Hopkins and other collegiate institution students, as well as on the current infrastructure for health promotion and mental health treatment. After careful consideration and discussion of this information, the committee makes specific recommendations, with the goals of health and wellness promotion, particularly increasing resilience in the context of stress, as well as mental illness prevention, and importantly, adequate mental health services for students when needed.

It is important to note that the Task Force was charged with making recommendations for all students. [1] An overarching sentiment surrounding these recommendations is the consideration that each division of the university, and, in some instances, specific programs within divisions, face distinct student mental health challenges. This arises in part because student mental health and wellbeing is context dependent – based on age, sex, cultural origin, gender identity, sexuality, disability, and other factors – and these demographics vary by program across the university. As a result, the tools and infrastructure opportunities for implementing recommendations also vary by division, as do the financial implications. Thus, while the committee has taken seriously the charge to make recommendations applicable across the university, some are division-specific and others will likely be implemented at varying degrees depending on divisional needs and resources.

Recommendation 1: The university should promote a climate of awareness and support for student mental health, wellness, and stress reduction. It is essential to create a campus climate that values inclusion of all students, overall wellness and that promotes resilience in the context of stressful situations and life events common among undergraduate and graduate student experiences.

1.a  The university should create a standing committee for mental health programming across Johns Hopkins called the JHU Mental Health Committee (MHC). MHC would serve to monitor the implementation of recommendations made by the Task Force, monitor the mental health programs across JHU, and provide advice to the President, Provost, and Vice Provost for Student Affairs. We recommend this standing committee include representation from across JHU, including staff responsible for monitoring and evaluating student mental health service delivery within and across divisions. Permanent members should include leadership of UHS, JHCC, JHSAP, Disability Services, and Associate Deans for Diversity and Inclusion, appointed by the Provost. Additional rotating members should include students from each school, as well as faculty and staff membership reflecting the diverse interests across the university. We recommend open applications and communication of a clear process for selecting rotating members based on qualifications and diversity of representation. Members would be expected to act as liaisons for their division/program to enable effective communication of their unit’s activities to the committee and the committee’s activities to their unit. Representatives from related JHU initiatives and offices should be invited to ensure consistency with mental health-related efforts such as substance use (e.g., Alcohol Strategies Working Group at Homewood), sexual violence, (Provost’s Sexual Violence Advisory Committee) etc.

We recommend this standing committee meet on a specific schedule, and provide annual reports to the Provost and President. Other tasks for this committee could include: engaging with the JED Foundation regarding best practices; monitoring services and policy integration across divisions, in collaboration with division or campus-specific advisory groups that oversee their specific needs; evaluating implementation of Task Force recommendations; monitoring the design and implementation of a communication strategy for student mental health; capturing student feedback via real-time survey methods (with both anonymous and signed options); and engaging with student groups (including those outside of JHU) regarding student mental health. This last point is critical given that student groups are involved in grassroots work to improve student mental health, and collaboration would support these existing efforts.

1.b  The university should develop and implement a university-wide communication strategy for student mental health. One of the key findings from the committee’s background investigations was the lack of knowledge among faculty and students about mental health generally, and more specifically, what resources are available, and from whom. It was also clear that to make a cultural change across the university, deliberate and coordinated messaging is necessary. Specific recommendations include:

1.b.1  Develop and maintain an easily navigated JHU-wide website on student health and wellbeing. It is very clear that a central landing spot for student mental health is needed that contains immediate information for students experiencing crisis, as well as general information about resources across the university. We recommend developing and maintaining a website that is an easy to find (via search engine optimization) hub of information for all JHU students, staff, faculty, and families. Careful attention should be paid to overlap with other websites and efficient linkages to those websites embedded. We recommend a university-level manager be responsible for development and oversight of this site, with monitoring by the MHC.

Suggestions for important content include:

• Crisis direction as an immediate banner.  This should include specific directions about who to contact if someone has immediate concerns about himself/herself or other students. Other ideas expressed by committee members included having a pointer to closest physical health care location (e.g., via zip code entry).

• Lists and contacts for service providers, partners (e.g. security), student organizations, campus disability and academic support services, and other campus resources for students that relate to mental health or overall wellness.

• A calendar of events that could include campus speakers related to mental health, training events, and social events related to wellness and stress reduction. This should be directly modifiable by appropriate staff at each division so as to eliminate a centralized bottleneck to communication.

• Printable brochures/posters regarding mental health and wellness.

• Information about eligibility and costs linked to services available to students.

• Information about, and links to, training modules available to students, staff, and faculty (specific trainings are discussed more in Recommendation 3).

• Information regarding general awareness and communication of concerns such as "what to look for, what to do."

• Link to a toolkit or app for self-help strategies, if such a toolkit can be identified that has an evidence base of utility end effectiveness.

• Link to the list of confidential resources on the Office of Institutional Equity website for victims of sexual assault.

• Options for anonymous and signed feedback about student mental health on campus to be communicated to the JH MHC.

1.b.2  Develop and implement frequent cultural messaging across JHU and within divisions that promotes mental health and wellness.  Changing the cultural norms regarding student health expectations is critical to promoting resilience. Changing cultural norms regarding inclusion and acceptance, including education about mental illness, can also greatly improve student outcomes. With this in mind, the committee recommends several communication initiatives:

• Consistent statements of JHU leadership’s commitment to student mental health.

• Expand mental health and wellbeing content and emphasis in orientations for all students. Content should set the tone of wellness culture and wellness strategies in the context of a highly rigorous academic setting in collaboration with community strategies above. This should include content and structured interactions on respect and inclusion of diverse student populations, in collaboration with diversity offices.

• Design and promotion of specific topic or subgroup-informed campaigns throughout the year. Examples include (1) anxiety reduction in a high-stress academic setting (not cool to avoid sleep, to compete for hardest working, etc.), (2) mental health stigma reduction, (3) perception of structural racism and bias against high-risk populations, (4) “look up” campaign (interpersonal communications rather than internet), (5) substance use awareness and safety (e.g., perceptions versus reality).

o   Strategies should consider mode, frequency, and target location/population for these campaigns. For example, modes of communication could include (1) information about mental health crisis contacts for faculty, staff, students on JHU identity badges, (2) brochures or cards located at highly frequented student locations, (3) magnets, pins, and stickers distributed at orientation, (4) strategic use of social media, and (5) mental health banners across campuses on lamp posts or other highly visible locations to convey the university’s commitment to this issue.

o   Frequency and target populations should be informed by known risk factors for mental health crisis such as (1) times of high stress around exams and transitions to college or holidays, (2) high-risk populations such as LGBTQ students, international students, etc.

• Engage and collaborate with other JHU offices and initiatives regarding communication strategies on topics related to wellness and mental health such as sexual assault, substance use, diversity and inclusion.

1.b.3  Coordinate with diversity offices to tailor communication for student populations at higher risk for mental health challenges. Based on the literature and JHU student surveys, these include international students, LGBTQ students, underrepresented minority students, military-affiliated students, students with disabilities, students with mental health concerns or diagnoses, first generation college students, single-parent students, students experiencing disciplinary action, and students experiencing violence in the community.

1.b.4  Develop and disseminate JHU-wide protocols and best practices on crisis and suicide responses. All divisions should develop and implement protocols for addressing crisis situations on campus and specific responses to student suicides, including following-up with classmates and faculty members (example in appendix, “After a Suicide Toolkit for Schools” goes beyond what is currently in JHU document).

1.b.5  Develop and disseminate JHU-wide protocols and best practices on how to support students who experience crime/trauma. All divisions should implement protocols, in consultation with corporate security, the Counseling Center, student deans, JHSAP, etc. to follow-up with students on campus who have been victims of a crime.

1.b.6  Hire or designate a Communications Coordinator in the Provost’s Office to direct the communication strategy and website development and maintenance. Implementation of these extensive communication strategies will require intentional coordination. The committee recommends institutional support for a university-level coordinator responsible for these initiatives.

1.c  The university should foster a supportive academic culture through faculty awareness, supportive faculty-student interactions, and appropriate academic programming. College and graduate education at a rigorous university is by its nature a challenging and potentially stressful experience, often coinciding with other critical life course events such as emerging adulthood, new independence, adult relationships, and family responsibilities. The university cannot entirely remove these sources of stress, but, rather, can offer a supportive academic environment that recognizes these challenges and supports students. With the goals of health and wellness promotion, particularly increasing resilience in the context of stress, as well as mental illness prevention, the committee recommends the following faculty and academic approaches: 

1.c.1  Require faculty to maintain training on student mental health.  This recommendation is elaborated in Recommendation 3.a below.

1.c.2  Engage the MHC to collaborate with the newly formed Second Commission on Undergraduate Education (CUE2), to inform and highlight academic and campus climate initiatives that will promote wellness and prevent mental health challenges. 

1.c.3  Facilitate and incentivize more frequent student-faculty engagement as a tool for promoting a supportive culture. Students consistently reported to this committee their desire for more frequent faculty engagement in social and personal settings to promote a culture of support and understanding. Faculty reported interest in this, but they have many demands on their time. Some incentive for faculty could help raise this as a priority, such as university-funded student-faculty lunches or dinners and/or faculty awards for student engagement.

1.c.4  Promote high quality faculty advising through (a) dissemination of best practices and (b) active monitoring, evaluation, and enhancement of advising to align with best practices. Specific tools will need to be implemented by divisions and programs. For example, faculty evaluations and recognition awards are tools to consider for advising quality promotion and correction. Several divisions already have student mentoring and advising awards that could be modeled.

1.c.5  Facilitate and require mental health and wellness sections of syllabi (as recently implemented by the Whiting School of Engineering). Content for these syllabus sections would include standard language on mental health, stress management and wellbeing, and links to the “new” website.  JHU can provide the template for such language, similar to sections on academic ethics that already exist. The information should also include information on access and eligibility for disability services. For some JHU Divisions, this can be automatically added to electronic syllabus templates. Some committee members also expressed that faculty should be encouraged to clearly articulate verbally during their courses that the instructor is open to being approached for guidance to resources.

1.c.6  Create subcommittee of the MHC that will engage with JHU Divisions regarding academic policies that affect student mental health. Several academic policies exacerbate mental health issues. For example, student surveys reported concern over the number of exams per day during finals, and this issue resonated with Associate Deans in many divisions. Policies to consider include, but are not limited to, course calendaring (including beginning and end of term dates and spacing of terms), policies on number of exams per day/week, and extensions for coursework due to family emergencies or mental health concerns. Engagement with divisions regarding these issues could include convening a committee of Deans of Education regarding structural solutions such as policies on number of exams per day or week and implementation strategies for such plans. Such implementation would presumably include faculty and TA training.

1.c.7  Effectively communicate medical leave of absence (MLOA) policies to students, faculty, and staff and ensure students, in collaboration with JHU mental health service providers, are properly supported while on leave and when returning to campus. The Task Force found that medial leave absence policies varied significantly among the divisions and both students and administrators often found them difficult to locate. While the Task Force found important reasons for each school to identify its own MLOA policy, the terms of those policies should be more easily accessible online to both students and administrators. In addition, each division, in consultation with the Counseling Center, UHS, and/or JHSAP, should have consistent procedures in place to communicate with students on MLOA to check on their progress and ensure they understand what is required to reenroll. 

1.d  Create partnerships and organize student government organizations to facilitate collaboration or grouping of student-led entities that focus on health and wellness.  For example, Homewood divisions currently have subgrouping by other non-health issues. In this case, the Task Force recommends that the SGA and student governments of each graduate program (GRO) create a new subgroup for health and wellness. The groups included in this category could be Active Minds, A Place to Talk, and CHEW.  By splitting off health and wellness groups into their own category that is directly sponsored by the Office of Student Life, these groups could get more direct support (financial, marketing, counsel, or otherwise), and students would more easily be able to learn about existing mental health groups.

Recommendation 2: The university should take necessary steps to improve student care at JHU mental health service providers and provide greater access to counseling services.

More than 60% of respondents to the JHU Student Mental Health Survey described the quality of care they received at the Counseling Center, JHSAP, and UHS as “good or very good.” However, many students become discouraged about long wait times to schedule an initial appointment and are dissatisfied with the lack of flexibility to change counselors. The Task Force believes the university should make strategic investments in its service providers to increase their ability to support students as demand for services continues to grow.

2.a  Create optimal organizational structures at each service provider. To keep pace with changing needs and increasing requests for mental health services, each of the 3 offices that provides mental health services to students should ensure the optimal organizational structure and staffing needed. These will differ depending on the current structure, staffing and unique demands of each office. However, by actively monitoring access including appointment wait times, demand for services and staffing ratios, mental health providers should ensure that students are seen in a timely manner according to established standards of access to each service. When demand for services increases, each service should have an established mechanism for evaluating whether additional staffing is required and have the ability to request resources for such staffing.

While the committee believes each service provider would benefit from an increase in staff in response to an increase in demand, we have identified an immediate need for additional staffing at JHSAP to help provide more timely service and further divide responsibilities from JHSAP and FASAP. The committee has outlined the specific staffing request for JHSAP in the text of this report in recommendation 2.b.2.  

2.a.1   Increase understanding among divisions about the differences in care provided by UHS and JHSAP.  Mental health and wellbeing is a continuum, and there is a spectrum of issues to address. JHSAP represents one end of this spectrum (i.e., treatment of primarily non-psychiatric conditions) and UHS represents the other end of the spectrum (i.e., treatment of primarily psychiatric conditions), it is recommended that there will be continuing discussions between the services and communication with faculty and staff to ensure that students are referred appropriately to the service that best meet their needs. In particular, for the Schools of Medicine, Public Health, and Nursing, JHSAP and UHS should work together to closely coordinate referrals to and from each service so as to direct patients to the service best suited for the student’s individual problem. This includes the timely sharing of medical information/records between services to ensure that treating providers have all the information necessary to assess and treat each student.

2.a2   The three service providers should develop a coordinated plan to provide additional support in the event of an emergency or traumatic event to prepare for a sudden increase in demand. The Committee found that UHS is particularly not prepared for short-term surges, so we recommend that mechanisms be put in place that allow for the quick recruitment of mental health providers at all levels if needed.

2.b  Increase Staffing to Improve Access within Johns Hopkins. The committee recognizes a critical need for additional staff at JHSAP and additional psychiatric providers within the JHMI network to ensure quicker access to a psychiatric provider. It can be very difficult to identify psychiatric providers in the community whom students can see in a timely manner. The committee makes the following recommendations to improve services in this area:

2.b.1 Complete an analysis of staffing to ensure optimal operational efficiencies at the three service providers. In order to help establish and maintain acceptable standards and enhance quality, it is recommended that a clinical practice analysis be conducted to determine the program needs of the Counseling Center and UHS to help keep up with evolving standards, conduct surveys and quality improvement projects, and that critical data analysis be performed periodically. This analysis should generate reports that would be incorporated into the work of the MHC.

2.b.2 JHSAP staffing in particular should be reviewed immediately in order to maintain quality service to BSPH, SOM and SON and provide service for the four schools who do not have access to UHS or JHCC (SOE, CBS, EP, SAIS). We recommend that in addition to current staffing needs, JHSAP add a psychiatric provider for students in these additional divisions, particularly in Washington, DC (where JHSAP serves SAIS and CBS students). We also recommend that JHSAP add staffing support to assist in clinical supervision as well as outreach and relationship building with schools. [2]

2.b.3 Expand capacity by creating greater collaborative arrangements with JHMI departments and programs, such as the JHH Department of Psychiatry. The Counseling Center frequently refers students to off campus psychiatric providers, and opening access to JHMI affiliated departments and programs would reduce wait times in scheduling appointments and furthers educational opportunities for residents.

 2.c  Ensure that students and trainees on both the Homewood Campus and East Baltimore have insurance plans that provides excellent behavioral health coverage. There are currently significant inconsistencies across divisions regarding mental health insurance coverage for students. When individuals become ill and require inpatient hospitalization or more complex medication regimens, it can be a major financial burden on the individual if there is inadequate coverage. Financial strain on an individual who is ill, in addition to the burden of the illness and stigma, can significantly exacerbate mental health problems. The Task Force recommends a review of coverage plans and waiver policies across the university that ensures inpatient, outpatient, and pharmaceutical coverage are not overly financially burdensome for students and are consistent with peer institutions. For example, none of the outpatient or inpatient departments within the Department of Psychiatry accept CIGNA insurance, which includes the CHP student insurance plan. These services are considered “out of network,” and students/patients are expected to self-pay at the time of services with a reduced rate.   

 2.d  Expand the current service hours of providers and explore opportunities for greater flexibility to accommodate student needs. Most of the service hours at each mental health provider are between the hours of 8am-5pm. Students have expressed concerns through the JHU Student Mental Health Survey regarding finding time during the day to schedule appointments during business hours. Access to and coordination of care may be improved by expanding service hours in some cases and taking advantage of alternative modalities of follow-up where possible. Therefore, we recommend that service providers expand to better suit the hours when students are not in class and during peak periods throughout the academic calendar to provide greater access to services.  

2.e  Increase communication about opportunities for anonymous contact with mental health services during crisis situations and opportunities to anonymously report concerns about the mental health of classmates. Many respondents of the JHU Mental Health Survey cited concerns about anonymity as a primary reason for not seeking counseling services. In addition, students overwhelmingly reported that they are more likely to discuss their mental health concerns with friends as opposed to professional counselors at JHU. Therefore, the committee specifically recommends the following actions:   

2.e.1  Advertise, and create where necessary, opportunities for students to engage anonymously with mental health services during mental health crisis situations. While on-going treatment at JHU service providers cannot be provided anonymously, initial, emergency consultations/assessments occur over the phone, and hotline resources are advertised as resources. Links to text and chat services should also be further explored as options. The university should also consider funding and staffing ISP suicide prevention strategies that can provide anonymous consultations with mental health professionals. 

2.e.2  Advertise, and create where necessary, opportunities for reporting student concerns about peers experiencing mental health challenges. Examples of tools for emergency reporting of peer concerns include the LiveSafe app through the Apple Store and Google Play that was piloted on the DC campus in 2015 and made available to Homewood students in 2016. Access to this app should be expanded to include campuses across the university. Examples of tools for non-emergency reporting include Homewood’s HopReach website, which provides an easy-to-use online platform to anonymously report concerns about a classmate. The Task Force notes that these examples have not been thoroughly evaluated for effectiveness on student mental health specifically. We recommend the MHC (Recommendation 1.a) consider monitoring the evidence base for peer reporting effects on student mental health and/or carrying out JHU-specific evaluations of that aspect of these apps. Nonetheless, given the strong support among students surveyed for anonymous reporting opportunities, we recommend implementation of currently available tools.

2.f  Increase coordination among mental health service providers. One of the positive outcomes resulting from the Task Force process has been the conversation, communication, and information sharing among the three service providers. This important relationship should continue to be supported and reinforced through the MHC discussed above. The Task Force identified the following three areas in which increased coordination among the providers would create efficiencies in the delivery of services for students:

 2.f.1  Develop a centralized referral list for local health care providers. It is critical to have an excellent  network of local health care providers to whom JHSAP, CC and UHS can refer. It would benefit all three providers if the university had an up-to-date centralized/shared database of community providers that is regularly vetted and updated to ensure quality assurance. The Task Force recommends that a FTE position be added that can be shared by all three providers to facilitate student referrals by assisting targeted recommendations based on insurance type, geographical location and provider expertise. This person would work in consultation with the Counseling Center’s referral coordinator.

2.f.2  Ensure that policies and protocols for responding to students in distress are consistent with a climate that supports and promotes mental health. The committee recognized that emergency or crisis situations involving students are often handled on a case-by-case situation, without consistency or coordination. A more structured operating procedure format should be created in all divisions to increase communication among relevant offices, protect the safety of students in distress, and ensure protocols are applied fairly. A set of protocols should be developed for emergency situations that ensures proper coordination among security, administrators, mental health providers, and Disability Services. These protocols should be easily accessible to students and should offer clear guidelines that help students understand their various options to access care at the school, including the option to select taking medical leave of absence if applicable.

2.f.3.  Ensure students with disabilities are properly informed of the process to receive appropriate             accommodations. Every effort should be made to provide information on this process through Admission,             Orientation and Student Services websites, course syllabi and other printed materials and to encourage             students to seek help early, as the process may take time. In some cases, students may need to submit             updated documentation. A referral list for the Baltimore/DC region of practitioners who can provide updated            documentation or testing, including information on those offering sliding scale fees, should be maintained by Disability Services and made available through the Disability Coordinators and their websites.

The Task Force recommends that the university investigate the possibility of contracting with a single source provider to find an affordable arrangement for students who may need updated documentation. In addition, Disability Services should regularly conduct assessments to determine the level of student and faculty satisfaction with their services and gather recommendations for improvements. The data collected should then be made available in an annual report to their constituents, including the MHC.

Recommendation 3: Offer, and in some cases require, training on mental health awareness and resources across faculty, staff, and students of the university.

Approximately 90% of suicides are committed by individuals suffering from untreated mental health disorders who are unlikely to self-refer for treatment. Mental health trainings increase the probability that a suicidal or distressed student would be identified by a member of the JHU community and referred to appropriate professionals for an assessment. Trainings also raise awareness about mental health, reduce stigma, and can help encourage suicidal or distressed individuals to seek professional mental health services for themselves.      

3.a  Require all teaching faculty to maintain training on student mental health (SMH) resources. Frequently, students with mental health difficulties show signs of distress in the classroom or begin to accumulate unexcused absences. The Task Force believes it is critical for all faculty to become better informed about mental health and be trained on appropriate responses if they are concerned about a student. Student responses from the Student Mental Health Survey, particularly in the qualitative data, indicate that JHU faculty generally do not understand or give proper weight to mental health issues.  

• The content of the trainings should include information on available JHU resources for students, identification of struggling students and how to engage with them, how to direct students with concerns about fellow students, best practices for regular “check-in” with advisees, best practices for crisis and death response, risk factors (transition times, at-risk populations) and information on how to support specific populations (international, LGBTQ, etc).

• Training should be an online module with a supplementary document about the content to be posted on our central website. Online options might include Kognito at Risk Program, Campus Connect, and Campus Clarity.

3.b  Require academic coordinators, teaching assistants, deans of education and students, JHU security officers, and student-facing staff (if not faculty covered above) to take mental health training. Recognizing that all students may not feel comfortable addressing mental health concerns with faculty, the Task Force believes it is necessary to provide mental health training to additional individuals within schools and departments who have frequent face-to-face interactions with students.

• The Task Force calls for an immediate need to require mental health awareness and crisis response trainings to JHU security officers. The Office of Corporate Security should provide Mental Health training to all JHU proprietary Campus Special Police Officers on an initial and annual in-service basis to help ensure that these officers are trained and prepared to recognize and properly respond to mental health crises incidents involving JHU students. The proposed training will be coordinated by the Corporate Security Training Division in consultation with the JHU Counseling Center.

• The Office of Residential Life should continue to require all residence assistants to receive training on student mental health resource and strategies and emphasize its importance, particularly during orientation. The trainings should include training on bystander help and peer supports.

3.c  Offer workshops and trainings regarding mental health and wellness to students, family members, non-student-facing staff members, and provide continuing education and training opportunities for mental health providers on campus. Results from the Mental Health Survey show that students are significantly more likely to discuss concerns about their mental health with friends or family members than university officials. The Task Force believes it is important to give students and family members the opportunity to learn more about mental health and how we can all better support each other. In addition, the research surrounding counseling and therapy techniques for best addressing mental health issues continues to evolve. It is important that JHU mental health providers be given an opportunity to continue their education through CE courses and additional training opportunities. Therefore, the Task Force calls for the university to make available:  

•  Student mental health training modules for all students and emphasize their importance to those in student organization leadership

• Student mental health training modules for family members (introduced at orientation and via distribution)

• CE courses and additional training opportunities to mental health providers to ensure they are adequately trained in evidence based practice

• Offer specific workshop and training opportunities for students tailored to specific populations on wellness topics such as:

·         Mental health first aid and crisis response

·         Bystander intervention

·         Time-management

·         Mindfulness and stress coping techniques

·         Life planning/management

·         Responsible substance use (details on how this is connected to current strategies in place)

·         Study skills

·         Conflict resolution

·         General classes on mental wellbeing (self-care, yoga, mindfulness, etc).